Arthritis can affect mental health through pain, inflammation, and lifestyle changes, which can lead to symptoms of anxiety and depression.
Conversely, mental health can impact arthritis through pain perception, reduced response to arthritis treatment, lifestyle changes such as poor adherence to treatment regimes, and inflammation.
Screening for mental health conditions in all patients with arthritis and discussing a treatment plan—which may include referrals to counseling and psychiatry—can improve their pain, disease management, and overall well-being.
Any form of arthritis—whether rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, lupus, gout, juvenile arthritis, fibromyalgia, or osteoarthritis—is associated with a negative impact on mental health.
In fact, the two are so closely linked that a mental health decline can also lead to worsening symptoms of arthritis.
Knowing this, HCPs may wonder if they should be screening for anxiety and depression in patients who suffer from arthritis. This, in turns, leads to more questions: Should mental health treatment be a part of overall disease management? And how can physicians do a better job at treating their patients without truly knowing what came first—the chicken or the egg?
Impacts of arthritis on mental health
According to the CDC, 1 in 5 patients with arthritis in the US have anxiety symptoms, compared with 1 in 9 patients without arthritis.
Additionally, depression symptoms double among patients with arthritis compared to those without.Related: Invisible symptom: The heavy toll of fatigue in inflammatory arthritis
The Arthritis Foundation states that pain contributes to anxiety and depression by causing physical and emotional stress which, in turn, incites neurochemical changes which worsen mental health.
Although living with chronic pain would be reason enough to provoke symptoms of anxiety and depression, it likely is not the only contributing factor, says the Arthritis Foundation. Lifestyle choices may also play an important role in the mental health of arthritis patients. People with arthritis often have limited mobility due to pain and have functional mobility of their joints, as well as general fatigue. This causes patients with anxiety to exercise less and become more socially withdrawn or isolated.
As exercise and socialization play an important role in regulating mood, the absence of them can often lead to worsening symptoms of anxiety and depression.
There is also an interesting inflammatory theory in relation to the impact of arthritis on mental health. A study published in The Journal of Clinical Psychiatry monitored CRP levels in just over 10,000 people who responded to the National Health and Nutrition Examination Survey. This study found that CRP levels were 31% higher in people with depression.
Many other studies show depression to be an inflammatory state with increase in cytokines. Researchers published a placebo-controlled trial in JAMA Psychiatry, showing a positive response to a TNF-alpha antagonist in patients with treatment-resistant depression and high inflammatory markers.
Impacts of mental health on arthritis
According to the CDC, patients with symptoms of anxiety and depression have a reduced response to arthritis treatment and reduced quality of life.
Treatment of mental health conditions can actually improve pain, irrespective of other pain management treatments. Why would this be so? The answer, once again, is likely multifactorial.
According to the Arthritis Foundation, pain and inflammation both likely play a role. Pain is subjective; it is understood that people experience pain differently depending on many factors, including, but not limited to, sleep, mood, and stress level. Therefore, depression and anxiety can make pain worse.
People experiencing pain as well as anxiety or depression are also less likely to adhere to treatment regimes. Therefore, treatment of their mental health condition can improve their perception of pain and improve their adherence to treatment.
The inflammatory theory may also have an impact on arthritis, as the effects may be cyclical in nature.
Treating the whole patient
All patients diagnosed with arthritis should be screened for symptoms of anxiety or depression.
This may include asking them simple screening questions based on the DSM criteria for depression and anxiety disorders, or physicians can instruct patients to fill out a formal screening tool, such as the PHQ-9 and GAD-7. Physicians may also want to discuss the link between arthritis and mental health with patients, and advise them to seek help when symptoms arise.
Physicians can also encourage exercise and social interaction. Depending on the functional impact of a patient’s arthritis and the type they have, this could include going to the gym, walking with friends, yoga, or even low-impact exercises such as swimming or water aerobics. Although exercise is important for maintaining functional ability, and in many cases is part of the treatment regime of arthritis, the added benefit of mood may be enough encouragement.Related: Wearable activity trackers may improve the health of patients with rheumatic disease
Finally, physicians can create a treatment plan with their patients that could include referrals. Depending on the physician’s specialty, management of anxiety and depression may be out of their scope of practice.
Facilitating a referral to a psychiatrist should be considered if the physician is not able to discuss the benefits and risks of antidepressant therapy.
Referrals should also be considered in treatment-resistant cases. Counseling should be considered for all patients with a diagnosis of anxiety or depression. Physicians can provide resources, such as arthritis education and local support groups, to encourage self-management and improve a patient’s coping skills.
As always with mental health conditions, screen for suicidal ideation and intent, taking appropriate action when needed as well as providing all mental health patients with local resources and phone numbers.
What this means for you
Arthritis alone is a painful and often debilitating disease. However, we as physicians need to make sure we are treating the person as a whole and recognize the link between arthritis and mental health conditions. In doing so, we may be able to better understand the entire picture, leading to better treatment results and patient satisfaction. In those patients that screen positive for anxiety or depression, a treatment plan should be put in place to include medication, referrals, counseling, support groups, and/or lifestyle recommendations.